International house calls: public health or public relations?

Inherent strengths of organization, speed, and efficiency commonly allow tactical military units, both land and sea based, to operate under hostile conditions as well as within adverse circumstances characterized by limited functioning societal infrastructure. Such qualities make them ideal for short term disaster relief operations. The events of 9/11/2001, however, prompted many strategic reassessments within the U.S. In the context of national security enhancements, a heightened interest evolved in augmenting activities dedicated to ensuring stability around the world. Emanating from this analysis was a directed elevation of “stability operations” (also known as stabilization and reconstruction operations) to core missions within the military. The new mandate marked a major shift in military responsibilities, espousing the strategic necessity to perform longer term peacekeeping and related stability operations, and, by so doing, hopefully maintaining, enforcing, promoting, and enhancing the possibilities for peace in unstable environments of the world.

In recognition of the desire to solidify the role of military activity in broader scale longer term humanitarian operations, responsibilities were formally assigned within the U.S. military for planning, training, and preparing to conduct stability, security, transition, and reconstruction operations throughout the world. In the past, many perceived such tasks as an inefficient use of military forces, these better left to other nations and non governmental agencies while the U.S. military concentrated upon operations requiring high intensity combat skills. Nevertheless, the new elevation of stability missions to the same priority as combat activities implied that future operations would regularly include efforts to both stabilize areas during transitions from war to peace, and then assist with reconstruction during these transitions. This further provided the basis for instituting significant changes in operational priorities, resulting in dedication of substantial resources to preparing troops to perform proficiently in such missions. Such efforts consequently required the systematic development of doctrine, training, education, exercises and planning capabilities to enable the armed forces to perform these operations proficiently, as well as the reconfiguration and acquisition of organizations, personnel, facilities and materiel to support them.Among these broad mandates was a directive designed to ensure that military medical personnel and capabilities are prepared to meet military and civilian health requirements in these stability operations.

In the foregoing context, given the prevalence of poverty, pestilence, and infectious diseases, as well as environmental and man-made devastation around the world, military health related humanitarian programs must ultimately be directed toward providing sustainable improvements in both the health status and quality of life of the populations targeted. An appreciation for the enormity and gravity of the health needs of targeted populations is therefore required.

The real problem: The extensive influence of infectious diseases, poverty, and politics in the developing world

Continued urbanization in the developing world, with changes in land and water use patterns associated with poor healthcare capabilities, abetted in part by the breakdown of public health systems due to war and economic decline, have been conducive to the spread of infectious diseases. Conversion of grasslands to farming in Asia, for example, has encouraged the growth of rodent populations carrying haemorrhagic fever and other viral diseases. Human encroachment upon tropical forests in South America has brought populations into closer proximity with both insects and animals carrying diseases such as leishmaniasis, malaria, and yellow fever. Close contact between humans and animals in the context of farming further increases the incidence of zoonotic diseases – those transmitted from animals to humans, such as recently noted in Asia through the rapid spread of avian influenza. Water management efforts, such as dam building, encourage the spread of water breeding vectors such as mosquitoes and snails, which have contributed to outbreaks of Rift Valley fever and schistosomiasis in Africa.

Throughout the world, twenty well known diseases including tuberculosis, malaria and cholera have re-emerged or spread geographically, often in more virulent and drug resistant forms. In addition, at least 30 previously unknown disease agents, for which no cures are available, have been identified. These include HIV, Ebola haemorrhagic fever, hepatitis C, Nipah virus, and the Marburg virus. Concurrently, frequent and sudden population movements within and across borders caused by ethnic conflict, civil war and famine continue to spread diseases rapidly in affected areas, particularly among refugees.

Outbreaks of Ebola haemorrhagic fever, which have occurred in several African countries, are thought to originate from human contact with infected monkeys and spreads among humans primarily through contact with infected persons. Outbreaks of avian influenza—spread by birds and sometimes infecting humans—have occurred in nearly 60 countries, killing millions of birds and more than 170 humans in 12 countries throughout Southeast Asia, the Middle East, and Africa as of 2007.

Persistent poverty, above all, sustains the least developed countries as reservoirs of infection throughout the world. These are already causing a major reduction in life expectancy in the most heavily affected sub-Saharan African countries, and will be spreading extensively throughout heavily populated Asia. Refugee camps found mainly in sub-Saharan Africa and the Middle East facilitate the spread of TB, HIV, cholera, dysentery and malaria. The trends will be especially evident in urban areas where malnutrition, overcrowding, poor sanitation, and polluted drinking water create conditions in which infectious diseases and relevant vectors such as mosquitoes and rodents thrive, thereby overwhelming health care infrastructures. Compounding these problems is the reality that microbial drug resistance continues to increase faster than the pace of new pharmaceutical and vaccine development, due in part to inappropriate use of antibiotics.

The same infectious diseases are not only likely to slow economic development in the hardest hit developing countries and regions, but they also challenge development and contribute to humanitarian emergencies and civil conflicts. The ultimate impact of infectious diseases is heavily influenced by the trajectory of developing and transitional economies, especially affecting the basic quality of life of the poorest groups in these countries. Most nations in the developing world possess stagnant economies tied to meagre agricultural dependencies. The severe economic impact of infectious diseases, particularly HIV/AIDS, and the infiltration of these maladies into the ruling political and military elites and middle classes of developing countries, further intensify the struggle for political power to control scarce state resources. These aforementioned dangers may exacerbate social and political instability in key countries and regions in which the developed world has significant interests.1 Clearly, the disease problems across the world are formidable, and it is debatable whether any inadequately delivered or poorly planned program of military assistance with indigenous health care, despite the best of intentions, can by itselfprovide a meaningful positive social impact. Under the new mandates regarding the development of strategic medical support capabilities, if military medical resources are to be utilized in humanitarian support activities the traditional principles and philosophies of military medical support must be expanded, and extensively modified to support relevant and effective medical operations in the developing world.

An Unvalidated Track Record Of Military Performance

During the twentieth century, previous U.S military medical activities, at the civic action level, were carried out in locations such as the Philippines, Central America, countries involved in World War II, Korea, and Vietnam. More recently, medical support operations were undertaken in Honduras, El Salvador, and subsequently in Haiti in 1994.Unfortunately, traditional medical civic action programs (MEDCAPS), carried out both officially and unofficially by U.S. military personnel for decades, or by subsequent medical readiness training exercises (MEDRETEs) in Central America, frequently represented a classic example of impatience and naiveté mixed with good will. Emphasis was placed upon production factors (outputs) during precipitous visits to isolated areas, where the number of patients seen, numbers of animals vaccinated, number of teeth extracted, etc., were more important than the achievement of a durable long term improvement in the health of the targeted population (outcomes)2. This mimicked the “body count” or “tonnage delivered on target” mentality so prevalent in the military during the Vietnam years. Furthermore, the focus was upon treatment rather than prevention. There were few or no plans for sustained integration with local government activities and personnel, and likewise no long term sustained follow-up of patients. U.S. personnel frequently lacked sufficient language skills and cultural training pertinent to the indigenous regions, and were often inadequately prepared to diagnose and treat many of those local diseases not generally seen in the U.S.

During a U.S. military medical assistance visit in Central America several decades ago, the observations of a U.S. Peace Corps worker highlighted previous military shortcomings in this dimension:

“There was nearly a feeling of religious devotion and expectation of that miraculous cure sought by those on the verge of despair . . . For the first two hours of the MEDCAP I saw only one person actually examined as doctors listened to complaints and wrote out prescriptions . . . The prescriptions that the doctors wrote were nothing more than scraps of paper with the name of a drug.Patients’ names and doses became a rarity as time progressed, as the doctors were unable to keep up with the flow of people.They also showed up with an inadequate supply of antibiotics, and we were forced to give half doses.Every child there was given medications for worms regardless of whether they had or did not have worms. Other medicines had little or no medical effect, such as Visine, vitamins and Tylenol or aspirin.As several of the medical personnel explained:‘Other than P.R. for the Army, we don’t do much of anything;’ ‘We don’t hurt anyone and if we get lucky maybe we help some;’ ‘We do a little Voodoo and make them think they are going to get well’ . . . Dona C., who was given Visine and vitamins for cataracts now realizes what a scam the Voodoo really was.At first elated, she is now bitter and depressed, knowing that she is going blind and that the Gringo Military lied to her . . . I doubt those officers have any idea of the harm they do, how they undermine the credibility of local health professionals, rob people of their incentive to work for change and control of their own lives, and accomplish nothing in the way of true health care . . . They undermine local professionals, contradict health educators, and reinforce age old ideas that people cannot help themselves . . . People had refused to be seen by the local doctor, and yet he is the one who will be there if follow-up care is needed.He is the one with a responsibility and commitment to the people, and can offer them care on a regular basis without the confusion and rush of the mob scene that the MEDCAP had become . . . The dentists too seemed to provide no service that could not have been rendered by our local odontologist.Sure, they pulled a lot of teeth, but that is not a need, for anyone can do that if need be.The true need in dental health is education as to hygiene, and prevention of tooth decay and gum disease . . . The people of the MEDCAP flew off as fast as they came, leaving the people no better off.They raised hopes of miracles, and left people bitter, disillusioned and frustrated” 3

Indeed, some observers held that traditional MEDCAP/MEDRETE activities were actually counter-productive to the overall goal of creating confidence in local governments4. Following civic action activities in Vietnam, Major General Edward Lansdale USAF, a pioneer in U.S. military special operations, noted that large U.S. units with their proliferating commands and bureaucracies commonly “stumbled over themselves” and were rarely effective. As he noted, “Too often they want to run their own programs at the expense of national ones and adopt a ‘let me do it for you’ stance, [which was] damaging to long term growth or improvement in the host country. They regularly stifle local initiative and too often endeavor to convert the programs of foreign nationals into mirror images of themselves”5. Lansdale further stated, “We came in so powerfully as a people, as a nation so organized in management…that we overwhelmed the problem. We continued to take the initiative away from the Vietnamese who would have to solve their own problems, but each time that we did that, we took away from the Vietnamese the right to solve their own affairs”6.

Medical civic action activities were likewise portrayed as fostering false impressions about local governments’ abilities to meet the populations’ needs by building expectations which could not be met after U.S. personnel departed. The local governments were viewed as being unable to care for their own, and consequently needed outside help to do so. Cosmetic efforts, amounting to little more than hit-or-miss uncoordinated activity, were actually more harmful in the long run than any good generated. In Vietnam, the perceived differences between American and Vietnamese hospitals, for example, were so pronounced that in some instances even seriously ill villagers were observed to demand American treatment before consenting to a MEDEVAC to a Vietnamese facility7.

Essential Requirements For Success: The Importance Of Disease Prevention

To counter the devastation of disease prevalent in affected territories, improved access to safe food and water is clearly required, as is childhood and adult immunization, in addition to the availability of essential drugs. Concurrently, a broad spectrum of social and economic assistance is required, otherwise identified as ‘nation building”, with health improvement being the ultimate goal. Efforts directed towards providing the physical and organizational infrastructure that populations need in order to re-establish normal lives are critical, such as enhancements of health infrastructure including clinics and hospitals. A variety of adjunctive services may also be required, such as medical assistance to refugee and impoverished populations.

Educational programs aimed at preventing disease exposure frequently depend upon higher literacy levels, and assume the existence of cultural and social factors which are often absent in those regions heavily burdened with infectious diseases. Underlying all proposed remedies, therefore, is the fundamental reality that indigenous health workers are critical factors for the success of any remedial programs. Such programs cannot be effectively fielded in their absence! Consequently, infectious disease control efforts can only be implemented by better assisting countries to deal with disease outbreaks themselves, through ensuring that locally trained indigenous experts are available to deal with such outbreaks, in addition to the availability of relevant vaccines and therapeutics.

During military civic action activities in Vietnam, General Lansdale emphasized the overwhelming necessity to improve peoples’ lives by both responsive and responsible indigenous governments8. Indeed, it is certainly reasonable to expect that future military involvement in foreign affairs through “nation building”, beyond supplying security and humanitarian aid in emergency situations, will have to be directed towards providing a range of activities to assist civilians themselves to arrest the spread of infectious diseases in their own countries. Such activities must realistically entail a long term commitment to furthering health education, primary level medical care, disease control and prevention, and most importantly, sanitation and public health advancement projects.

Organizational Remedies

Because of the traditional far-reaching geographic interests of the U.S., attention had previously been directed toward enhancement of foreign policy objectives through the medium of military delivered health care assistance, albeit on a short term tactical level. Military health care support was often included within humanitarian relief offerings to populations ravaged by the after effects of armed conflict, disease, pestilence, and unforeseen calamities of nature. (The latter was recently seen after the tsunami disaster in the Bay of Bengal and adjacent territories in 2004, as well as following the profound earthquakes in northwest Pakistan in October 2005 and fatal mud slides in the Philippines in February 2006).

The operative concept for stability and humanitarian activities, however, focuses on the full range of military support that the future joint force might provide in foreign countries across the entire continuum from peace to crisis and conflict. Contingently, US military forces must be prepared to perform all tasks necessary to establish or maintain order when local resources and governments cannot do so. This implies a responsibility, at home or abroad, to provide support for stabilizing and administering occupied territory, and caring for refugees in major combat operations. It likewise includes the responsibility to assist a stable government that has been struck by a devastating natural disaster, and to provide military assistance and training to partner nations that increase their capability and capacity to conduct stabilization, security, transition, and reconstruction operations.

Certainly, the armed forces may be needed in hostile environments to provide security for relief workers providing humanitarian assistance such as health care. If health assistance is deemed appropriate, however, given the profound indigenous disease prevalence in the developing world, community based military sponsored projects, emphasizing the sustained training and support of village health care workers, must be key objectives in any effort. The ultimate goal is the establishment of a true network of local health care promoters within the targeted areas, regions, and countries. (For example, several decades ago the Cuban government properly identified the primary health care provider as a critical element in facilitating extension of its sphere of influence within the “Third World” setting. Cuban foreign policy, for years, consistently addressed this issue. Cuba undertook long term commitments to grass roots health improvement projects in rural sections of the Third World, at the village level and below. This involved, as a cornerstone, grass roots sanitation promotion, health education, and austere low level medical care. Language capable Cuban personnel, trained in the diagnosis and treatment of local (endemic) diseases, were posted to such positions for long term commitments, functioning in low profile, low visibility positions, with paradoxically high sustained impact. [Even in Grenada, at the time of the U.S. invasion in 1983, most rural health posts were staffed by Cubans, who were living with the people.] In addition, local citizens were transported to Cuba to train as rural health providers [as physicians, nurses and technicians]. The overall emphasis of the Cuban program was upon preventive medicine and health improvement. More recently in 2006, in an effort to expand Cuba’s Latin-American hegemony, a reported 708 of its physicians and health care volunteers have been dispatched to set up similar low level health care clinics throughout indigent areas of Bolivia.)

The Global Emerging Infection Surveillance And Response System

An earlier effort by the military services in the direction of international health enhancement, and a model worthy of future expansion, is exemplified by the Global Emerging Infection Surveillance and Response System (GEIS), established in 1996. In response to a directive to identify emerging infectious diseases worldwide, the services were called upon to support global surveillance, training, research, and response to infectious disease threats. GEIS activities included establishing laboratories in host countries, training host-country staff in surveillance techniques, providing advanced diagnostic equipment, and development of laboratory diagnostic capabilities. During 2005-2006, for example, approximately $8 million was obligated through GEIS to more than 60 projects for infectious disease surveillance that helped build capacity in five developing countries where the U.S. military has maintained overseas research laboratories, namelyEgypt, Kenya, Indonesia, Peru, and Thailand. Many of the GEIS projects, co-located in 36 other countries, are conducted jointly with host-country nationals. While the stated primary goal of the GEIS program is conducting surveillance of infectious diseases abroad to protect military health and readiness, many projects including surveillance activities, conducted jointly with host-country nationals, provide opportunities to build local capacity through their participation in these projects.

GEIS program activities have indeed led to improved surveillance capacity for infectious diseases in some host nations. In Nepal, for example, GEIS funded surveillance of febrile illnesses such as dengue fever, and through this project provided a field laboratory with training and equipment to conduct advanced diagnostic techniques. This effort, along with several other projects at the site, transformed the laboratory from a facility for shipping specimens into a fully functional infectious disease surveillance laboratory. In Egypt, GEIS funded a surveillance system for the rotavirus, the most common cause of severe diarrhoea among children. As part of this effort, clinicians and laboratory personnel in Libya, Bahrain, Jordan, Sudan, Syria, and Yemen were trained in conducting surveillance for this disease. GEIS also funded more direct training. The laboratory in Peru, for example, conducted an outbreak investigation training course for public health officials from Peru, Argentina, Chile, and Suriname in 2006. GEIS also helped to establish an electronic surveillance system in Indonesia, Laos, Cambodia, and Vietnam, as well as another version of the system in Peru, that improved the timely detection of, and response to, infectious disease epidemics.

Strategic Considerations For An Appropriate Medical Program

Cadres of U.S. medical specialists with appropriate language fluency, educated in the cultural nuances of the regions supported, must be developed to support strategic health care projects. This requires people well trained in the diagnosis, treatment and prevention of diseases unique to the region, operating under clear and well defined policy and operational guidelines, rather than untrained personnel lacking the ability to speak the local language, merely sent out to remote areas to “show the flag” and dispense untold quantities of pharmaceuticals. These cadres may well include a spectrum of health care providers – individuals with not only military medical skills, but also those trained in practical facets of the general medical disciplines, including Preventive Medicine and Public Health, as well as in the primary care skills inherent in the areas of Paediatrics, Obstetrics, Gynaecology and Psychiatry.

In preparing military health care personnel for humanitarian operations, the training goals should be pragmatic, adapted to the cultural and economic realities of the region, and not focused upon a wholesale adoption of western medical standards. The performance expectations of such personnel should not exceed their training, and their job skills should match the desired requirements. The medical and social status of military representatives should match those of their local counterparts, and their standard of living should be similarly austere and commensurate with local standards and customs. Humility and understanding are keystones of any relationships. This includes status consciousness within the context of local customs, and downplaying the appearance of competition with the established healthcare system, while attempting to understand the politics of public health in the local region9. (When discussing Vietnam, it was therefore with good reason that General Lansdale believed it essential for Vietnamese leaders to claim credit for any successes, changes, and reforms resulting from humanitarian activities)10.

Other capabilities that may be required by local indigenous agencies include facilities, communications, and medical intelligence data such as disease prevalence rates in specific regions. All of these are items with which the U.S. military has extensive expertise, such as the GEIS project, notwithstanding its long term experience with innovative engineering and public health projects including sanitation and potable water source development. U.S. military forces likewise contain a highly trained and disciplined work force, as well as state of the art medical and intelligence systems. Furthermore, they constitute one of our nation’s most important resources in the fields of tropical public health and tropical medicine, notwithstanding their broad capability in large scale immunization development and delivery.

Not only a cadre of military health service foreign area specialists must be developed, but a career pattern must be designed to provide multiple opportunities for work in designated areas of the world for both long term health care promotion and security assistance purposes. Each military service must develop its own cadre of regional experts for service in those parts of the globe where it is the sole military representative of our national interests. This requires the assumption of long term placement commitments in order to earn the friendship and respect of the local populace; not the traditional one to six month temporary assignments heretofore characteristic of such positions.

Organizational Imperatives

Medical nation building efforts also require the integration of planning and programming at the national executive level in accordance with existing policies. Consequently, at the administrative level, regional medical experts are needed to further assist in the development of policy, concept, doctrine, organization, plans and requirements for health services as well as public health support in these various settings. In addition, a sub-cadre of medical information and intelligence collectors, trained with technical knowledge regarding medical matters and the biological sciences should be positioned worldwide to increase the flow of raw scientific and technical medical intelligence information.

The Importance Of Program Integration

Ultimately, to achieve a fully integrated strategic, operational or tactical humanitarian support plan, combatant commanders and their staffs require increased knowledge of the roles, responsibilities, and capabilities that other agencies and organizations can contribute to stabilization efforts. Collaboration with them is imperative! For example, in response to the realities within the developing world, international organizations such as the World Health Organization and the World Bank, as well as the US Centers for Disease Control and Prevention, in addition to a host of internationally based Non Governmental Organizations (NGOs), are already playing a critical role in attempting to strengthen both international and national surveillance and response systems for infectious diseases. As such, trained health service foreign area specialists must be assigned to both military and local non-military local advisory groups to facilitate integration of efforts and coordination.

According to a recent Government Accountability Office audit, although the military services have developed and continue to facilitate an approach to enhance humanitarian health operational capabilities mediated through combatant commanders and local diplomatic representatives, they have encountered not only challenges in identifying and addressing capability gaps, but likewise have failed to develop those measures of effectiveness which are critical to successful execution of operations. Indeed, recent high visibility public relations enhancement activities such a hospital ship cruises, in themselves, may be inadequate for insuring the durability required for sustained health achievement in humanitarian activities without well conceived metrics for defining effectiveness, as well as retrospective analysis of lessons learned11.

Current guidance must clearly articulate a systematic approach to both prioritizing needed capabilities and, above all, development of measures of effectiveness. Clear methodology must be developed as well as time frames for completion, to let stakeholders take ownership in identifying the metrics and procedures for evaluating and validating assigned humanitarian tasks. Ultimately, however, validated long term effectiveness must be the prevailing standard.